AFFILIATE MEMBERSHIP APPLICATION Name of Country/Township Committee, Organization or Association: *AddressCity StateZipTelephone: *FAX:Key Contact:Position:E-Mail: *Check All Areas of Involvement that Apply: *Mental HealthSubstance UseDevelopmental DisabilitiesOther (describe)Category of Organization: *Group initiating referendumProvider OrganizationCommunity Mental Health CommitteeAssociationPlease provide a brief explanation of your interest in becoming an Affiliate Member of ACMHAI: Submit
